Cannabinoid Hyperemesis Syndrome CHS: Causes, Symptoms & Treatment

Imaging should be avoided, especially in the setting of a benign abdominal examination, as there are no specific radiological findings suggestive of the diagnosis. The SAEM GRACE program addresses the best practices for the care of the most common chief complaints that can be seen on the tracking board of any emergency department in the country, based upon research and expert consensus. These guidelines are designed with de-implementation as a guiding principle to reasonably reduce wasteful testing, provide explicit criteria to reduce foreseeable risk, and define sensible and prudent medical care.

Twenty-four additional articles were identified through the bibliographies of articles returned in the primary search. After removal of duplicates, 1253 abstracts were independently screened by reviewers, of which 170 satisfied criteria for inclusion. The strength and quality of each study were evaluated using the GRADE working group metrics 83. Grading and Recommendations Assessment, Development, and Evaluation (GRADE) defines high-quality studies as randomized trials or double-upgraded observational studies. Moderate-quality studies are defined as downgraded randomized trials or upgraded observational studies. Low-quality studies are defined as double-downgraded randomized trials or observational studies.

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Cannabinoids are compounds in the Cannabis sativa plant that bind to cannabinoid receptors in your brain, spinal cord, gastrointestinal tract and other body tissues. Examples of cannabinoids include tetrahydrocannabinol (THC) and cannabidiol (CBD). Despite the increasing popularity and legalization of cannabis in many states, there remains a lack of consistent and comprehensive public health policies to address cannabis-related disorders like CHS. Unlike alcohol and tobacco, which have well-established health warnings and regulations, cannabis products are not universally required to include health warnings or educational materials. Public health policies could include mandatory inclusion of warnings on cannabis product labels about the potential for CHS, especially for frequent users, and guidance on https://ecosoberhouse.com/ safe consumption.

• Treatment of CHS typically occurs during the hyperemetic phase, which often requires hospitalization due to the severity of symptoms.
• In this phase, patients frequently experience intractable nausea and vomiting that is unresponsive to conventional antiemetic medications 33.
• This study is limited by the heterogeneity of the case series and case reports and the lack of controlled studies examining this syndrome.
• Animal studies lend some credibility to this theory; however, results are not consistently reproducible in human studies.

Review

In populations where cannabis consumption is normalized or even celebrated, patients may feel hesitant to disclose their usage or the symptoms they experience, fearing judgment from healthcare providers or the broader community. This barrier to disclosure could result in delayed diagnosis of CHS and other cannabis-related health issues, potentially leading to prolonged suffering or more severe complications. Policies promoting a non-judgmental, open discussion about cannabis use in healthcare settings could help overcome this barrier.

The experimental evidence behind these inferences illustrates the complexity of the pathophysiology of CHS and raises many additional questions. Other hypotheses were identified, but the data to support them were so limited as to not warrant discussion in this review 57, 84–87, 89, 91, 99–105, 107, 122, 126, 138–165. Per the consensus guideline, treatment should focus on symptom relief and education on the need for cannabis cessation. Capsaicin is a readily available topical preparation that is reasonable to use as first-line treatment. Antipsychotics including haloperidol and olanzapine have been reported to provide complete symptom relief in limited case studies.

Population Health Research Capsule.

Patients may report that hot water alleviates symptoms, causing some to spend several hours in the shower 11. Until the past decade, marijuana, specifically THC, had been largely illegal to possess and use, and its legalization has prompted new medical insights into its effects, both positive and negative. The use of marijuana has surged significantly in recent years, fueled by legalization efforts and increasing societal acceptance. As of December 2024, all but four states have full or partial legal marijuana laws or decriminalization laws in effect 2.

Studies exploring novel treatments, diagnostic criteria, or the pathophysiology of CHS were also prioritized. Two reviewers (CS and AM) independently reviewed all titles generated by the search to identify potentially relevant articles. Articles that were clearly not relevant based on title and abstract were excluded. The articles were then segregated into diagnosis, pathophysiology, or treatment categories. When the two reviewers disagreed on article eligibility, a consensus was reached through discussion.

In addition to the supportive measures mentioned above, certain pharmacological treatments have shown promise in alleviating symptoms. Haloperidol, a dopamine antagonist and antipsychotic often used off-label as an anti-emetic 36, has demonstrated effectiveness in halting intractable vomiting in CHS patients, with symptom cessation reported as early as one hour after administration 37. Capsaicin, applied to the abdomen, has shown success in resolving symptoms in all 15 CHS patients studied in one case report and two case series 38-40. This effect is thought to be mediated through capsaicin’s interaction with the TRPV-1 receptor, which plays a role in the endocannabinoid system and may modulate nausea and vomiting pathways 41. Initial reports describe an average of 7.1 emergency department visits, 3.1 hospitalizations, and 5.0 clinic visits prior to diagnosis 12, but as the syndrome is recognized more and cannabis availability increases, more rapid diagnosis is likely.

We would like to express our appreciation for the assistance provided by OpenAI’s ChatGPT in the development of this manuscript. The use of this advanced AI tool facilitated the clarification of complex concepts and contributed to the refinement of our written work. Its support in enhancing the structure and flow of the manuscript proved invaluable. While ChatGPT’s contributions were instrumental in streamlining the writing process, the authors amphetamine addiction treatment remain fully responsible for the integrity and content of this article.

Pergolizzi et al. 20 provide an in-depth exploration of the pathogenesis of CHS. Cannabis contains over 100 different cannabinoids, with delta-9-THC and CBD being the primary compounds. These cannabinoids bind to cannabinoid receptors type 1 (CB1) and type 2 (CB2), which are distributed throughout the body. Specifically, CB1 receptors are primarily located in the brain, while CB2 receptors are found outside the central nervous system (CNS), in areas like the spleen, thymus, and other immune cell populations 21.

SAEM GRACE-4: Alcohol Use Disorder and Cannabinoid Hyperemesis Syndrome Management in the Emergency Department

• The absence of specific biomarkers for CHS means that physicians must rely primarily on clinical history, which can be challenging when the patient does not openly disclose cannabis use or when cannabis use is intermittent.
• Twenty-four additional articles were identified through the bibliographies of articles returned in the primary search.
• Opioids may exacerbate CHS symptoms due to their association with bowel dysfunction, and they could also potentially lead to opioid dependence in chronic users 47.
• There is a clear need for more robust studies to assess the prevalence, demographics, and long-term outcomes of CHS in a variety of populations.
• This information is not published but raises questions regarding the role of an unidentified molecule, whether cannabinoid or non-cannabinoid (e.g., a pesticide) may precipitate of the syndrome.

Many hypotheses exist, yet there is very limited evidence to support any one unifying mechanism. The best evidence suggests a dynamic interplay between cannabinoid metabolism and complex pharmacodynamics at the CB-1 receptor. In addition, our study identified three unique cases of CHS caused by synthetic cannabinoids 23, 41, 182. These agents are potent agonists of the cannabinoid CB1 receptors, similar to THC, suggesting that agonism at the CB1 receptor may be responsible for CHS.

The authors gratefully acknowledge Eric C. McDonald, MD, MPH, Medical Director, Epidemiology & Immunization Branch, County of San Diego, Health & Human Services Agency for his contributions to the CHS expert consensus guideline. Researchers created a concise expert consensus CHS guideline focusing on avoiding opioid analgesia and unnecessary work-ups. Check lab reports for cannabinoid and terpene profiles to align with your needs. Southern Medical Association is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.